Provider Demographics
NPI:1669905832
Name:HAYNES FAMILY OF PROGRAMS
Entity type:Organization
Organization Name:HAYNES FAMILY OF PROGRAMS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STRTP ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-593-2581
Mailing Address - Street 1:233 WEST BASELINE RD
Mailing Address - Street 2:BOX 400
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2353
Mailing Address - Country:US
Mailing Address - Phone:909-593-2581
Mailing Address - Fax:909-614-7466
Practice Address - Street 1:233 WEST BASELINE ROAD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2353
Practice Address - Country:US
Practice Address - Phone:909-593-2581
Practice Address - Fax:909-833-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0175.00.02OtherFACILITY LICENSE